Eye-Opening Ideas for Staff
The concept of ongoing education is being applied to physicians' office staffers as well, doctors and insurers report. Teaching employees how they can keep a tense situation from exploding into an ugly lawsuit may be-short of clinical perfection, which everyone knows is impossible-a physician's best way to minimize malpractice liability exposure.

"Your staff plays a key role in your patients' overall perspective of your practice," Farber says. "If staffers are not professional or friendly, they leave the impression that they don't care about patients. Physicians should continually monitor operations within their practices to ensure that everyone has a goal of patient safety and good quality care. Patients who sue are often angry because they were not heard or attended to."

Flashpoint situations where it's evident a patient is unhappy and where non-MD staffers can make or break the successful resolution of the issue include late appointments, unanswered patient phone calls, patient refusal to pay a bill, missing test results and failure to communicate test results, particularly when an outcome requires follow-up.

One way to ensure these situations don't devolve into litigation is staffing the practice with carefully selected, thoroughly trained professionals. "To minimize staff's negative impact on a patient's desire to sue, physicians should hire carefully and train staff," Farber says. "Training should include not only technical procedures, but required telephone etiquette, lines of authority, handling of complaints or unusual events, and opportunities to discuss daily activities."

Training is especially important for physicians making significant changes in their practices. "Many physicians are beginning to set up different types of practices and to offer services that are outside what they have done in the past," Farber says. "They need to pay particular attention to new exposures, such as practicing outside their areas of expertise and taking on responsibility for the actions of others-such as massage therapists, estheticians and others who offer not strictly medical services." In particular, Farber notes, the explosion of cosmetic services being offered by all types of physicians "substantially" increases their liability exposure.

Barbara Worsley, vice president of risk management at The SCPIE Companies, Los Angeles, says physicians must think more like team members. "Doctors don't practice medicine in a vacuum," she says. "The entire healthcare team-the billing manager, the medical records clerk, the receptionist, the medical assistant-has an active and absolutely key role to play in malpractice prevention."

Some frequent malpractice allegations include failure to follow up, failure to monitor and delayed referrals. "[The allegations] have nothing to do with a physician's clinical skills, but are reflective of the functions of the practice," Worsley says. "That's where the involvement of the staff-and its proficiency and professionalism-are absolutely essential."

Indeed, a doctor's staff often has much more contact with patients than the doctor himself or herself. "The staff has to be aware of the importance of its role in communicating with patients," Worsley says. "We know the physician is a patient advocate, but we need to focus more on the fact that the physician surrounded by his or her team forms the whole molecule of patient advocacy."

However, staffers need to make sure they don't make things worse in their desire to help out. "Sometimes people on the team don't recognize their scope of practice," Worsley says. "Medical assistants have to be very careful that they do not cross over the line and perform functions outside their scope. And you cannot have receptionists giving medical advice-like telling a patient it's probably OK if the next appointment is in eight weeks instead of four. That may seem benign, but there have been lawsuits where the receptionist was assessing the patient's condition."

Doctors must take the lead in keeping everyone on track, Worsley emphasizes, even if they feel they don't have the time to be involved. "It's just like in football," she says. "You have a quarterback, but that quarterback needs to know what the running back is going to be doing, what the wide receiver is going to be doing and what the line is going to be doing. He has to understand every person's responsibilities."

Even if doctors haven't made the effort to monitor the performance of their staff, their patients surely do, says Waldene Drake, vice president of risk management and patient safety at CAP-MPT, Los Angeles. "Patients generally know they are not competent to evaluate medical care, but they do feel able to evaluate the level of service received from the professional staff," she says.

Doctors' staffs are measured just like other service professionals. "Patients who receive courteous service and a smile at their bank may not tolerate their doctor's office staff treating them rudely or in a dismissive way," Drake says. "If the office is so disorganized that patients wait 50 minutes in the waiting room, they compare it to the speedy checkout at their local market."

The key, says Richard Anderson, MD, chair and CEO at The Doctors Co., Napa, is doing more in the area of customer service training. Customer service is a critical focus in other industries, but because most medical practices are small, training is often "informal and limited," he says.

"You hire people you assume are responsible and bright, but the truth is there's often not much training offered for handling situations where people may be annoyed," Dr. Anderson says. "The most important thing to do is make sure appropriate staff members are skilled at triage. We don't expect assistants to be physicians, but we do expect that they have a sense of what's urgent and what isn't."

In some ways, a staff member's sense of urgency translates into the doctor's ability to defuse a potential malpractice lawsuit. So experts agree doctors should consider developing an enlightened staff an essential form of malpractice prevention.